• Appropriate Test Ordering • Delayed Access/Results • Misinterpretations Test Management • Timely Triage • Comprehensive History/Physical • Access to Medical Records/PCP Initial Assessment • Reassessment/Vital Signs • Communication of Changes • Escalation Ongoing Monitoring • Availability of Services • Timeliness/Delay • Curbside Consults Specialty Consultation • Language Barrier • Engagement • Comorbidities/Bias Patient Factors Production Pressure / Environment Culture Communication Documentation • Unit Staffing • Volume/Acuity • Bed Management/Boarding A CLOSER LOOK WHY EDs ARE VULNERABLE The diagnostic process is complex. Providers must gather, integrate, and interpret data and apply clinical judgment. ED care teams need to coordinate and communicate input from testing, ongoing assessment, and consultations. The diagnostic process can break down even in optimal settings, and ED environments are often far from optimal. Systems issues, combined with fast-paced, high-acuity environments, make EDs particularly vulnerable to error. Chaos can contribute to diagnostic error, particularly when many medical encounters involve an incomplete medical history and disrupt collaborative processes and feedback loops. Furthermore, some patients are discharged before test results are back, leaving voids in completing the diagnostic process. Additionally, some patients do not return when symptoms persist or worsen, so the feedback loop is never closed. The chart below illustrates the many complexities facing ED care teams. ( 5 ) | HIDDEN IN PLAIN SIGHT | Exposing the Drivers of Diagnostic Error A DOSE OF INSIGHT ® Coverys |